TIBIAL FRACTURES
From the 8th Annual Chicago Trauma Symposium
| TIBIAL SHAFT FRACTURES: CURRENT CONCEPTS—Jeffrey O. Anglen, MD, Professor and Chair, Department of
Orthopaedics, Indiana University School of Medicine, Indianapolis
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| Epidemiology: tibia most commonly fractured long bone; most low-energy injuries (increasing among elderly)
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| Assessment: compartment syndrome—missed diagnosis common cause of lawsuits; diagnosed by palpating for tension
in soft tissues and finding pain on passive motion; paresthesia first sign; develops over time; continue to look for
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| Treatment options: closed treatment with functional bracing; intramedullary (IM) nailing; plate fixation (primarily
for periarticular fractures); external fixator (primarily for soft tissues)
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| Closed treatment: consider conservative management; in discussed example, unnecessary surgery led to disastrous
outcome; avoid prolonged casting
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 | Functional fracture bracing: short period of cast immobilization followed by activity in well-fitted brace and progressive
weight-bearing; acceptable shortening and angulation; nonunion rate <1% in 450 cases (healed in ≈16 wk)
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| Examples: long-leg cast (shaped like leg; snug-fitting; ankle at 90°; knee extended); functional patellar tendon-
bearing cast (cut-out in back allows knee motion; walking heel; 90° at angle; molded to allow bearing through
front of tibia); off-the-shelf functional fracture brace (hinged ankle; ankle cup; plastic shell held on with Velcro
strips; shaped like leg; fits in shoe; allows early weight-bearing)
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| Surgical indications: open fractures; severe soft-tissue injury; compartment syndrome; highly unstable fractures;
consider for significant comminution, unacceptable shortening on initial x-ray, >50% translation, or segmental
fractures; high risk for deformity (fibula intact; spiral fractures with tibia and fibula broken at different levels); ipsilateral
femur; floating knee; intra-articular fractures; failures of conservative care
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| Surgical choices: external fixator for soft-tissue injuries; plating for periarticular injury; IM nailing for tibial shaft fractures
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| Surgical options and outcomes: based on prospective randomized studies; nail heals faster (eg, 16 wk vs 12 wk;
patients likely to prefer delay in healing, especially with risk for IM sequestrum); knee and ankle scores better; expensive;
no good comparisons in literature for IM nailing vs functional fracture bracing; reamed compared to unreamed
nailing—better healing; fewer secondary procedures (most minor, eg, screw removals); appears safe in
open fractures; plating vs external fixator vs IM nailing for open fractures—plating discouraged; external fixator
better than plating; nailing best option (for severely contaminated fractures, consider delayed nailing or other option)
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| Example of nailing procedure: mid-shaft tibia fracture (some comminution; fibular fracture same length); apply
femoral distractor on medial side (allows more stable reduction with less surgical help); pin parallel to each joint
(proximal pin slightly posterior; renders somewhat valgus); small incision at inferior pole of patella; starting awl
aligns with medullary canal of tibia; open canal with T-handle reamer; knee in slight flexion; guidewire should lie in
center distally; ream slowly; irrigate; do not use tourniquet (blood flow removes heat, avoiding risk for heat necrosis);
measure length; switch out guide rod; insert nail over guide rod; free-hand technique for distal interlock; blocking
screw (positions nail in relation to small proximal fragments)
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| HIGH-ENERGY INTRA-ARTICULAR DISTAL TIBIA FRACTURES—Mark Reilly, MD, Associate Professor, Department
of Orthopaedics, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark
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| Epidemiology: average patient 35 to 40 yr of age; associated injuries increasing (eg, airbags fail to protect feet)
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| Mechanism of injury: high-energy—fall from height; motor vehicle accident; lower energy—skiing torsional
fractures
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| Significance of tibial pilon fractures: foot and ankle injuries affect outcome of multiply injured trauma patient;
impact of isolated fractures lifelong; “therapeutic nihilism”—expecting patients to do poorly; defines success as
lack of major complications; underestimates achievable goals and potential outcomes; nonoperative
management—reserved for nondisplaced fractures
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| Staged protocol: proposed after open treatment of low-energy twisting injuries achieved good results (high rates of
return to work; low rates of complications); over time, open treatment applied to higher-energy injuries, resulting in
poorer prognoses, increased complications linked to soft tissues and deep infections; as consequence, delaying surgical
treatment seen as way to reduce complications; emergence of staged protocol—results reported in 1999; now
standard therapy; immediate external fixation and treatment of fibula; followed by delayed treatment of tibial pilon
fractures; significantly reduced complications
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| Soft-tissue injury: treatment of soft tissue key to overall success; poor surgical timing—virtually guarantees poor
outcome
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| First stage: fixation of fibula; transarticular external fixation (enables stabilization of soft tissues and bringing tibia out
to length); definitive articular reconstruction; removal of fixator; computed tomography (CT) to evaluate results
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| Stage 1 goals: restore skeletal length; provide distraction across ankle joint; align talus under tibia
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| Plating fibula fracture: posterolateral incision (midway between posterior border of fibula and Achilles’ tendon; allows
most options for later placement of incisions for tibial component); avoid potential malalignment—
fixation must allow control of fibular length, angulation, and rotation; posterior lateral fragment (Volkmann’s)
remains attached to fibula by distal tibiofibular ligament; placement of distal fibula in space determines position
of fragment in space
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| Applying fixator: transarticular fixator applied with transfixion pin through calcaneus and 2 pins in tibia; medial-
based fixator also used
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| Applying dressing: bulky compressive dressing; wait until soft tissues can tolerate surgical intervention: wait for
resolution of edema, positive wrinkle test, and epithelialization of fracture blisters; requires patience; takes ≈10
days for soft tissue microvascularity to return to status 2 hr after injury; waiting period 14 days, 24 days in original
reports on protocol
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| Second stage: surgical approach normally anteromedial or anterolateral; usually dictated by mechanically appropriate
location of fixation; standard articular injury involves 3 fragments—anterolateral; osteoarticular (Volkmann’s),
attached to distal fibula; mediomalleolar (medial shoulder of articular surface); areas of articular
impaction and comminution located between fragments
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| Fibula: assess fracture to determine mechanical fixation; (fibula intact in axial loading injury; difficult to treat); tension
failure—varus injury; distal fibula tends to displace into varus; requires medial-based implant and medial buttress
plate fixation; anteromedial implant placed through anteromedial approach; deep dissection stays medial to
tendon of tibialis anterior; incise extensor retinaculum; perform anteromedial capsulotomy; use external fixator or
femoral distractor for direct articular visualization; compression failure—valgus injury; distal tibia tends to displace
into valgus; requires anterolateral-based implant; incision in line with fourth metatarsal, centered at ankle joint;
perform transverse joint arthrotomy; remove transarticular external fixator; apply small distractor or small external
fixator from anterior talar neck to middle aspect of tibia for visualization; incision in line with fourth metatarsal;
entire extensor shelled out after incision of retinaculum, mobilizing musculature medially to expose anterolateral
fragment; articular comminution accessed through fracture line
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| TIBIAL MALUNIONS—Dr. Reilly
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| Truly malaligned: distinguish between deviation from normal healing, and deformity causing problem for patient;
excessive deformity of length, alignment, angulation, rotation, or translation produces functional impairment
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| Causes of malunion: failure to obtain or maintain reduction with nonoperative or operative (IM nailing) treatment
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| Long-term effects of nonunion: overloading causes cartilage shear forces and degeneration of femoral condyle;
altered contact pressures in knee and ankle joints seen in cadaveric studies; clinical studies suggest increase in osteoarthritis
(OA), functional limitation, and patient complaints; 2 studies found no significant increase in rate of
OA from “relatively small degrees of malunion”
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| Assessing need for surgery: depends on patient needs, and functional and symptomatic limitations; begins with
understanding deformity
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| Evaluate deformity for: angular, rotational, and length discrepancies; orientation of knee and ankle joints; effects
on mechanical and weight-bearing axis of limb
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| Length: clinically—measure distance from knee to heel in prone position; radiographically—scanogram; x-ray of
tibia over radiopaque ruler; difficult in significant angular deformity
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| Rotation: clinically—assess axis of motion of knee and ankle joints; radiographically—fluoroscopy for true lateral
images of knee and ankle to determine degree of discrepancy
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| Angular malalignment: determine anatomic alignment of fragments; draw illustration of fragments, with intersecting
lines to define center of rotation and angulation; translational deformity—center of rotation moves away from
apex
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| X-rays: anteroposterior (AP) and lateral views reveal one angular deformity out of plane with 2 x-rays; measure
angulation on each x-ray to calculate true plane and angle of deformity; “no-angulation view”—under fluoroscopy,
rotate leg to identify plane with no deformity; take x-ray orthogonal to plane to reveal plane and magnitude
of maximal displacement
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| Indications for osteotomy: ligamentous instability on convex side of deformity; leg-length discrepancy >2 cm;
inability to place foot on floor; unicompartmental knee; OA; malrotation >20°; patient healthy and active; radiographic
criteria relative (based on functional demands of patient; slight valgus more tolerable than varus; shift in
mechanical axis poorly tolerated)
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| Preoperative planning critical: operating room (OR) logistics; previous surgical approaches performed; optimal
configuration of osteotomy; means of correction (femoral distractor; external fixation; plating); available implants;
bone grafting
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| Choice of osteotomy: closing wedge (if shortening acceptable); opening wedge (if lengthening needed); neutral
wedge (opening on one side, closing on other); transverse osteotomy (deformity rotational); distraction osteogenesis
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| Single-plane mathematical oblique osteotomy: probably most useful and commonly used; allows control and
correction of both angular and rotational deformities; placed in plane parallel to no-angulation view; determine angle
of osteotomy to shaft of bone (based on amount of rotation and angulation required, determined with scientific
calculator); advantages—produces broad surfaces; optimal for lag-screw fixation and neutralization plate; enables
increasing length
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| Stabilization: select best option
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| IM nail: less surgical dissection and soft-tissue irritation; earlier weight-bearing; disadvantages—difficult if canal
obliterated; metadiaphyseal malunions difficult (useful in selected patients; better in diaphyseal malunions); less
precise correction of deformity; variable stability
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| Plate fixation: assists correction of deformity; more precise correction; better initial stability; versatile (proximal,
distal, and metadiaphyseal malunions); disadvantage—more surgical dissection and implant irritation; longer
time to full weight-bearing; applications—complex angular and rotational deformities; proximal or distal metadiaphyseal
deformities (when soft tissues good or reconstructible after osteotomy)
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| External fixation: useful in complex multiplanar deformities needing length restoration; can minimize need for
bone grafting; useful in poor soft tissues or previous infections; versatile (allows early weight-bearing);
disadvantages—requires compliant tolerant patient; stressful for patient and surgeon; pin tract sepsis; long duration
of treatment; frame application technically demanding; applications—prior infections; poor soft tissues
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| Avoiding trouble: understanding of deformity; preoperative planning; good fixation; compress osteotomy; careful
patient selection
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| PANEL DISCUSSION—Drs. Anglen and Reilly; Michael D. Stover, MD, Assistant Professor, Department of Orthopaedics,
Loyola University Chicago, Stritch School of Medicine, and Chief of Trauma, Loyola University Medical Center,
Maywood, IL; Michael S. Sirken, MD, Assistant Professor, Department of Orthopaedics, University of Medicine and Dentistry
of New Jersey, New Jersey Medical School, Newark, NJ
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| Nonsteroidal anti-inflammatory drugs (NSAIDs) and smoking in nonunions: Dr. Reilly—evidence
shows smoking (nicotine) and NSAIDs impair fracture healing; tries to get patients to stop smoking and discontinue
NSAIDs; does not refuse to treat patients who cannot quit smoking
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| Nail or plate in commuted tibial fractures? Dr. Stover rarely uses nail currently (useful when skin too poor for
plating); chooses percutaneous plate for multi-fragment proximate tibial fracture; locked plate in bicondylar plateau
fractures—choice of plate depends on bone healing environment and ability to obtain reduction on medial
side; less-invasive stabilization system (LISS) fixator used in patients without bone healing problem and no coronal
split on healing; fixes medial side first
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| Blocking-screw placement: Dr. Anglen—determine in preoperative planning; usually on lateral side to prevent
varus deformity and on posterior side to prevent anterior deformity
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| Cause of anterior knee pain after IM nailing: unknown; not related to incision; leaving nail proud causes
pain; Dr. Stover—temporary pain, caused by incision
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| Fibular fixation in pilon fracture: Dr. Reilly—fixing fibula helpful in establishing limb length and reducing tibial
fracture; no cut-off on distance of fibular fracture above joint for decision to fix; usually fixes fibula; managing
patients on referral (if complicated fibular fractures, applying temporizing fixator alone before referral preferable; if
simple fibular fracture, fix fibula and apply frame before referral
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| Wound management: Dr. Sirken—bead pouches used in large soft-tissue defects; if flap also needed, vacuum-
assisted wound closure (VAC) useful; without defect, debride tissue and loosely reapproximate skin, followed by
second debridement (beads placed in dead space under skin
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| When to take second look into open fractures: Dr. Sirken—depends on condition of soft tissue before fixation;
not always necessary; if uncertain, second look advised
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Suggested Reading
Anglen JO et al: A comparison of reamed and unreamed nailing of the tibia. J Trauma 39:351, 1995; Bhandari M
et al: Early versus delayed operative management of closed tibial fractures. Clin Orthop Relat Res Nov(368):230,
1999; Bhandari M et al: Treatment of open fractures of the shaft of the tibia. J Bone Joint Surg Br 83:62, 2001;
Dunbar RP et al: Provisional plating of Type III open tibia fractures prior to intramedullary nailing. J Orthop
Trauma 19:412, 2005; Healy WL et al: Distal femoral varus osteotomy. J Bone Joint Surg Am 70:102, 1988; Martinez
A et al: Closed fractures of the proximal tibia treated with a functional brace. Clin Orthop Relat Res
Dec(417):293, 2003; McKellop H et al: Control of motion of tibial fractures with use of a functional brace or an external
fixator. A study of cadavera with use of a magnetic motion sensor. J Bone Joint Surg Am 75:1019, 1993; McKellop
HA et al: Effects of tibial malalignment on the knee and ankle. Orthop Clin North Am 25:415, 1994; Nork SE
et al: Intramedullary nailing of distal metaphyseal tibial fractures. J Bone Joint Surg Am 87:1213, 2005; Nork SE et
al: Intramedullary nailing of proximal quarter tibial fractures. J Orthop Trauma 20:523, 2006; Sanders R et al: Oblique
osteotomy for the correction of tibial malunion. J Bone Joint Surg Am 77:240, 1995; Sarmiento A et al: 450
closed fractures of the distal third of the tibia treated with a functional brace. Clin Orthop Relat Res Nov(428):261,
2004; Sarmiento A et al: Functional bracing in the treatment of delayed union and nonunion of the tibia. Int Orthop
27:26, 2003; Sarmiento A et al: Functional fracture bracing. J Am Acad Orthop Surg 7:66, 1999.
Educational Objectives
| The goal of this program is to enable orthopaedic surgeons to better manage tibial fractures. After hearing and assimilating
this program, the clinician will be better able to:
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| 1. Choose between intramedullary (IM) nailing and plate fixation in managing tibial shaft fractures.
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| 2. Avoid complications in high-energy distal tibia fractures.
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| 3. Employ a staged protocol in managing high-energy distal tibia fractures.
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| 4. Recognize appropriate indications for treating tibial nonunions.
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| 5. Perform osteotomies designed to treat various tibial nonunions.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose
relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any
identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary
business or commercial interest. For this program, the following has been disclosed: Dr. Anglen—EBI, Inc
(consultant).
Acknowledgements
The speakers were recorded at the 8th Annual Chicago Trauma Symposium, Matthew J. Jimenez, MD, Course Chairman.
The Audio-Digest Foundation thanks the speakers and Dr. Jimenez for their cooperation in the production of
this program.
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